Changes in End-of-Life Symptom Management Prescribing among Long-Term Care Residents during COVID-19

OBJECTIVE

To examine changes in the prescribing of end-of-life symptom management medications in long-term care (LTC) homes during the COVID-19 pandemic.

DESIGN

Retrospective cohort study using routinely collected health administrative data in Ontario, Canada.

SETTING AND PARTICIPANTS

We included all individuals who died in LTC homes between January 1, 2017, and March 31, 2021. We separated the study into 2 periods: before COVID-19 (January 1, 2017, to March 17, 2020) and during COVID-19 (March 18, 2020, to March 31, 2021).

METHODS

For each LTC home, we measured the percentage of residents who died before and during COVID-19 who had a subcutaneous symptom management medication prescription in their last 14 days of life. We grouped LTC homes into quintiles based on their mean prescribing rates before COVID-19, and examined changes in prescribing during COVID-19 and COVID-19 outcomes across quintiles.

RESULTS

We captured 75,438 LTC residents who died in Ontario's 626 LTC homes during the entire study period, with 19,522 (25.9%) dying during COVID-19. The mean prescribing rate during COVID-19 ranged from 46.9% to 79.4% between the lowest and highest prescribing quintiles. During COVID-19, the mean prescribing rate in the lowest prescribing quintile increased by 9.6% compared to before COVID-19. Compared to LTC homes in the highest prescribing quintile, homes in the lowest prescribing quintile experienced the highest proportion of COVID-19 outbreaks (73.4% vs 50.0%), the largest mean outbreak intensity (0.27 vs 0.09 cases/bed), the highest mean total days with a COVID-19 outbreak (72.7 vs 24.2 days), and the greatest proportion of decedents who were transferred and died outside of LTC (22.1% vs 8.6%).

CONCLUSIONS AND IMPLICATIONS

LTC homes in Ontario had wide variations in the prescribing rates of end-of-life symptom management medications before and during COVID-19. Homes in the lower prescribing quintiles had more COVID-19 cases per bed and days spent in an outbreak.

Measuring the Use of End-of-Life Symptom Relief Medications in Long-Term Care Homes-a Qualitative Study

Background

At the end of life, individuals may experience physical symptoms such as pain, and guidelines recommend medications to manage these symptoms. Yet, little is known about the symptom management long-term care (LTC) residents receive at the end of life. Our research team developed a metric-whether residents receive one or more prescriptions for an end-of-life symptom management medication in their last two weeks-to explore end-of-life care for LTC residents. This qualitative study aimed to inform the refinement of the end-of-life prescribing metric, including the acceptability and applicability to assess the quality of a resident's symptom management at end-of-life.

Methods

We conducted 14 semi-structured interviews with Ontario health-care providers (physicians and nurses) who work in LTC homes and family caregivers of residents who died in LTC. Interviews were conducted virtually between February 2021 and December 2022, and were analyzed using thematic analysis.

Results

We identified three major themes relating to perceptions of the metric: 1) appropriateness, 2) health-care provider applicability, and 3) caregiver applicability. Participants noted that the metric may be appropriate to assess end-of-life care, but noted important nuances. Regarding applicability, health-care providers found value in the metric and that it could inform their practice. Conversely, caregivers found limited value in the metric.

Conclusion

The proposed metric captures a very specific aspect of end-of-life care-whether end-of-life medications were prescribed or not. Participants deemed that the metric may reflect whether LTC homes have processes to manage a resident's end-of-life symptoms with medication. However, participants thought the metric could not provide a complete picture of end-of-life care and its quality.

Palliative End-of-Life Medication Prescribing Rates in Long-Term Care: A Retrospective Cohort Study

BACKGROUND

Medications are often needed to manage distressing end-of-life symptoms (eg, pain, agitation).

OBJECTIVES

In this study, we describe the variation in prescribing rates of symptom relief medications at the end of life among long-term care (LTC) decedents. We evaluate the extent these medications are prescribed in LTC homes and whether prescribing rates of end-of-life symptom management can be used as an indicator of quality end-of-life care.

DESIGN

Retrospective cohort study using administrative health data.

SETTING AND PARTICIPANTS

LTC decedents in all 626 publicly funded LTC homes in Ontario, Canada, between January 1, 2017, and March 17, 2020.

METHODS

For each LTC home, we measured the percent of decedents who received 1+ prescription(s) for a subcutaneous end-of-life symptom management medication ("end-of-life medication") in their last 14 days of life. We then ranked LTC homes into quintiles based on prescribing rates.

RESULTS

We identified 55,916 LTC residents who died in LTC. On average, two-thirds of decedents (64.7%) in LTC homes were prescribed at least 1 subcutaneous end-of-life medication in the last 2 weeks of life. Opioids were the most common prescribed medication (overall average prescribing rate of 62.7%). LTC homes in the lowest prescribing quintile had a mean of 37.3% of decedents prescribed an end-of-life medication, and the highest quintile mean was 82.5%. In addition, across these quintiles, the lowest prescribing quintile had a high average (30.3%) of LTC residents transferred out of LTC in the 14 days compared with the highest prescribing quintile (12.7%).

CONCLUSIONS AND IMPLICATIONS

Across Ontario's LTC homes, there are large differences in prescribing rates for subcutaneous end-of-life symptom relief medications. Although future work may elucidate why the variability exists, this study provides evidence that administrative data can provide valuable insight into the systemic delivery of end-of-life care.

Association between non-medical cannabis legalization and emergency department visits for cannabis-induced psychosis

A major public health concern of cannabis legalization is that it may result in an increase in psychotic disorders. We examined changes in emergency department (ED) visits for cannabis-induced psychosis following the legalization and subsequent commercialization (removal of restrictions on retail stores and product types) of non-medical cannabis in Ontario, Canada (population of 14.3 million). We used health administrative data containing the cause of all ED visits to examine changes over three periods; 1) pre-legalization (January 2014-September 2018); 2) legalization with restrictions (October 2018 - February 2020); and 3) commercialization (March 2020 - September 2021). We considered subgroups stratified by age and sex and examined cocaine- and methamphetamine-induced psychosis ED visits as controls. During our study, there were 6300 ED visits for cannabis-induced psychosis. The restricted legalization period was not associated with changes in rates of ED visits for cannabis-induced psychosis relative to pre-legalization. The commercialization period was associated with an immediate increase in rates of ED visits for cannabis-induced psychosis (IRR 1.30, 95% CI 1.02-1.66) and no gradual monthly change; immediate increases were seen only for youth above (IRR 1.63, 1.27-2.08, ages 19-24) but not below (IRR 0.73 95%CI 0.42-1.28 ages, 15-18) the legal age of purchase, and similar for men and women. Commercialization was not associated with changes in rates of ED visits for cocaine- or methamphetamine-induced psychosis. This suggests that legalization with store and product restrictions does not increase ED visits for cannabis-induced psychosis. In contrast, cannabis commercialization may increase cannabis-induced psychosis presentations highlighting the importance of preventive measures in regions considering legalization.

Characterization of Problematic Alcohol Use Among Physicians: A Systematic Review

IMPORTANCE

Problematic alcohol use in physicians poses a serious concern to physicians' health and their ability to provide care. Understanding the extent and characteristics of physicians with problematic alcohol use will help inform interventions.

OBJECTIVE

To estimate the extent of problematic alcohol use in physicians and how it differs by physician sex, age, medical specialty, and career stage (eg, residency vs practicing physician).

EVIDENCE REVIEW

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020-compliant systematic review, searching Medline, Embase, and PsychInfo from January 2006 to March 2020. Search terms included Medical Subject Headings terms and keywords related to physicians as the population and problematic alcohol use as the primary outcome. The quality of studies was assessed using the Newcastle-Ottawa Scale. We included articles where problematic alcohol use was measured by a validated tool (ie, Alcohol Use Disorders Identification Test [AUDIT], AUDIT Version C [AUDIT-C], or CAGE [Cut down, Annoyed, Guilty, and Eye-opener] questionnaire) in practicing physicians (ie, residents, fellows, or staff physicians).

FINDINGS

Thirty-one studies involving 51 680 participants in 17 countries published between January 2006 and March 2020 were included. All study designs were cross-sectional, self-reported surveys. Problematic alcohol use varied widely regardless of measurement method (0 to 34% with AUDIT; 9% to 35% with AUDIT-C; 4% to 22% with CAGE). Reported problematic alcohol use increased over time from 16.3% in 2006 to 2010 to 26.8% in 2017 to 2020. The extent of problematic use by sex was examined in 19 studies, by age in 12 studies, by specialty in 7 studies, and by career stage in 5 studies. Seven of 19 studies (37%) identified that problematic alcohol use was more common in males than females. Based on the wide heterogeneity of methods for included studies, limited conclusions can be made on how problematic alcohol use varies based on physician age, sex, specialty, and career stage.

CONCLUSIONS AND RELEVANCE

Studies about problematic alcohol use in physicians demonstrate a high degree of heterogeneity in terms of methods of measurement, definitions for problematic alcohol use, and cohorts assessed. Most studies are primarily self-reported, precluding the ability to determine the true prevalence among the profession. Few studies provide relevant comparisons to aid in identifying key risk groups for targeted interventions.

Efficacy and safety of a new immunoglobulin G product, Gammaplex(®), in primary immunodeficiency diseases

This open-label multi-centre study evaluated a new intravenous immunoglobulin, Gammaplex®, in the treatment of 50 patients with primary immunodeficiency and significant hypogammglobulinaemia. Patients treated previously with other intravenous immunoglobulins received Gammaplex® on their same infusion schedule for 1 year; 22 were on a 21-day and 28 on a 28-day regimen (300-800 mg/kg/infusion). There were no serious, acute bacterial infections, whereas six subjects (12·0%) had at least one such infection in the 6 months before enrollment. Forty subjects (80·0%) had at least one non-serious infection; the median number of infective episodes per subject per year was 3·07. Antibiotics were taken by 38 subjects therapeutically and prophylactically by 16 at some time. Fewer than half (46·0%) missed any time off work or school because of infection or other illness. Trough immunoglobulin (Ig)G levels were above 6·00 g/l in all subjects at all assessments after 15 weeks with two exceptions. Overall, 21·2% of infusions were associated with an adverse event up to 72 h after infusion. The frequency of adverse events increased with infusion rate. Headache was the most common product-related adverse event (7·5% of 703 infusions). In conclusion, Gammaplex® is effective in primary immunodeficiency and is well tolerated.

IMPDH1 promoter mutations in a patient exhibiting azathioprine resistance

Around 9% of inflammatory bowel disease (IBD) patients are resistant to azathioprine. We hypothesized that these patients may carry mutations within inosine-5'-monophosphate dehydrogenase (IMPDH). To test this hypothesis, we screened 20 azathioprine-resistant patients for variations in the two IMPDH genes (IMPDH1 and IMPDH2) using dHPLC and DNA sequencing. A 9 bp insertion within the IMPDH1 P3 promoter was found in a patient exhibiting severe azathioprine resistance. The insertion is predicted to abolish a cAMP-response element (CRE) and was found to significantly reduce IMPDH1 P3 promoter activity in a luciferase reporter gene assay (P-value <0.001). This in vitro assay suggests the variant promoter has altered function in vivo and consequently may have contributed to the thiopurine resistance observed in this patient. The absence of functional variants within the other patients indicates that if IMPDH genetic variability contributes to azathioprine resistance it does so infrequently.

Thiopurine methyltransferase and 6-thioguanine nucleotide measurement: early experience of use in clinical practice

BACKGROUND

Azathioprine and 6-mercaptopurine (6-MP) are well established for the treatment of inflammatory bowel disease (IBD). Assessing thiopurine methyltransferase (TPMT) status has been recommended to reduce the risk of serious toxicity. Measuring red blood cell (RBC) 6-thioguanine nucleotide (6-TGN) concentrations has been recommended for dose adjustment.

AIM

To describe the results of measuring TPMT activity and genotype, and 6-TGN concentration in New Zealand.

METHODS

Canterbury Health Laboratories provided these analyses for New Zealand. Those with low TPMT activity also underwent genotyping. All results were collated and analysed descriptively. 6-TGN concentrations were correlated with the dose of thiopurine when known.

RESULTS

TPMT enzyme activity (range 1-22 U/mL) from 574 patients showed a trimodal distribution. Genotyping results matched this distribution with only mild overlap between (*1/*1) homozygote and (*1/*3) heterozygote groups. One patient without TPMT measurement before therapy had life-threatening neutropenia and was later found to have (*3/*3) genotype. TPMT analysis probably prevented two further such cases. Of 884 6-TGN concentrations (range 0-1434 pmol/10(8) RBC), 41, 39 and 20% were within, below, and above the therapeutic range of 235-450 pmol/10(8) RBC, respectively. Leucopenia was seen in some patients with high 6-TGN. 6-MMP concentrations in 177 patients with low 6-TGN suggested non-compliance in 31, underdosing in 130, and preferential metabolism of 6-MP to 6-methylmercaptopurine in 16. There was poor correlation between azathioprine dose and 6-TGN concentration (r(2) = 0.002), supporting 6-TGN monitoring.

CONCLUSIONS

Measurement of TPMT enzyme activity and 6-TGN concentration has been well-integrated into clinical practice. These tests should reduce the risk of toxicity and improve efficacy with thiopurines in patients with IBD.

Thiopurine S-methyltransferase (TPMT) genotype does not predict adverse drug reactions to thiopurine drugs in patients with inflammatory bowel disease

BACKGROUND

Azathioprine and mercaptopurine (MP) are well established treatments for inflammatory bowel disease but they have severe adverse effects that prevent their use in some patients. The likelihood and type of adverse effect may relate to thiopurine methyltransferase (TPMT) enzyme activity and genotype.

AIM

To compare the TPMT genotype frequencies in patients with inflammatory bowel disease who have had severe adverse effects to those who tolerate azathioprine or MP (controls).

METHODS

Patients with inflammatory bowel disease who had been treated with azathioprine or MP in Christchurch between 1996 and 2002 were identified. Patients with adverse effects, and controls, were invited to provide a peripheral blood sample for analysis of TPMT genotype. The genotype frequencies were then compared between the two groups.

RESULTS

Fifty-six patients were identified with adverse effects requiring cessation of therapy, of which 50 were genotyped. Reactions included allergic-type (25%), hepatitis (33%), nausea/vomiting (14%), bone marrow suppression (10%), pancreatitis (6%) and other (12%). Five of 50 patients with reactions had TPMT genotype *1/*3, one had *3/*3, and the rest had the wildtype genotype *1/*1. The patient with genotype *3/*3 had severe pancytopenia requiring hospitalization. Three of 50 controls had the *1/*3 genotype and the rest were *1/*1.

CONCLUSIONS

The TPMT allele frequency in our population with inflammatory bowel disease is similar to that reported elsewhere. There was a slight trend for more frequent TPMT mutations in the patients with adverse reactions, but this was not statistically significant. Most patients with reactions did not have gene mutations.

A common P-glycoprotein polymorphism is associated with nortriptyline-induced postural hypotension in patients treated for major depression

The multi-drug resistance gene ABCB1 (or MDR1) encodes a P-glycoprotein (P-gp) that regulates passage of many substances across the blood-brain barrier. The antidepressant amitriptyline and its metabolites (including nortriptyline) are substrates for P-gp, and in mice lacking P-gp, penetration of amitriptyline, but not fluoxetine, into the brain is enhanced. We reasoned that polymorphic variation of P-gp may contribute to differing responses of patients to antidepressant drugs. A single nucleotide polymorphism (SNP) of ABCB1 (3435C>T) was recently correlated with expression levels and in vivo function of P-gp. We examined this SNP in patients with major depression enrolled in a randomized antidepressant treatment trial of nortriptyline and fluoxetine, and observed a significant association between nortriptyline-induced postural hypotension and 3435C>T (chi(2) = 6.78, df = 2, P = 0.034). Our results suggest that homozygosity for 3435T alleles of ABCB1 is a risk factor for occurrence of nortriptyline-induced postural hypotension (OR = 1.37, P = 0.042, 95% CI 1.01-1.86).

Alterations in lipoxygenase and cyclooxygenase-2 catalytic activity and mRNA expression in prostate carcinoma

Recent studies in prostate tissues and especially cell lines have suggested roles for arachidonic acid (AA) metabolizing enzymes in prostate adenocarcinoma (Pca) development or progression. The goal of this study was to more fully characterize lipoxygenase (LOX) and cyclooxygenase-2 (COX-2) gene expression and AA metabolism in benign and malignant prostate using snap-frozen tissues obtained intraoperatively and mRNA analyses and enzyme assays. Formation of 15-hydroxyeicosatetraenoic acid (15-HETE) was detected in 23/29 benign samples and 15-LOX-2 mRNA was detected in 21/25 benign samples. In pairs of pure benign and Pca from the same patients, 15-HETE production and 15-LOX-2 mRNA were reduced in Pca versus benign in 9/14 (P=.04) and 14/17 (P=.002), respectively. Under the same conditions, neither 5-HETE nor 12-HETE formation was detectable in 29 benign and 24 tumor samples; with a more sensitive assay, traces were detected in some samples, but there was no clear association with tumor tissue. COX-2 mRNA was detected by nuclease protection assay in 7/16 benign samples and 5/16 tumors. In benign and tumor pairs from 10 patients, COX-2 was higher in tumor versus benign in only 2, with similar results by in situ hybridization. Paraffin immunoperoxidase for COX-2 was performed in whole mount sections from 87 additional radical prostatectomy specimens, with strong expression in ejaculatory duct as a positive control and corroboration with in situ hybridization. No immunostaining was detected in benign prostate or tumor in 45% of cases. Greater immunostaining in tumor versus benign was present in only 17% of cases, and correlated with high tumor grade (Gleason score 8 and 9 vs. 5 to 7). In conclusion, reduced 15-LOX-2 expression and 15-HETE formation is the most characteristic alteration of AA metabolism in Pca. Increased 12-HETE and 5-HETE formation in Pca were not discernible. Increased COX-2 expression is not a typical abnormality in Pca in general, but occurs in high-grade tumors.

Mealworm feeders as environmental enrichment for common marmosets

The impact of a foraging enrichment device, the "mealworm feeder," on the behavior of the common marmoset was examined. In 3-h weekly exposures to the wormfeeder device, behavioral observations were conducted to compare the rates of feeder use, use of other enrichment devices, stereotyped behavior, and inactivity, to those of control sessions in which the enrichment device was not provided. Significantly decreased rates of pacing and time spent sitting still were observed in association with placement of the mealworm feeder. Feeder use declined over a period of 3 h, even if the feeders' contents were not fully depleted, and the effects of enrichment on activity waned in a like fashion. Use of other enrichment devices, comprised primarily of cage furniture, increased in the presence of the mealworm feeder. This effect did not change significantly over the 3 h of exposure even though use of the feeder declined. There was significant variation in feeder use among sex and housing condition, with females housed singly and in peer groups using the feeders significantly more than did males, whereas subadults used the feeder significantly more often than did either the dominant female or male in family groups. The results of this study suggest that the mealworm feeder is an effective form of environmental enrichment for the common marmoset, but interest wanes after approximately 3 h.

Prolactin levels are elevated after infant carrying in parentally inexperienced common marmosets

Alloparental behavior (parental behavior directed to nondescendant young) is pervasive among human cultures but rare among other mammals. New World primates of the family Callitrichidae, including common marmosets (Callithrix jacchus jacchus), dwell in large families and many family members carry and/or provision infants. This study experimentally characterized alloparenting in common marmosets by measuring infant retrieval and carrying outside of the context of the family group. Prolactin was measured in samples collected before and after infant exposure to determine whether elevated prolactin levels were predictive of alloparental responsiveness. Seventeen nonbreeding, parentally inexperienced, singly or peer-housed common marmosets (10 females, 7 males, 6-66 months of age) were tested repeatedly in an infant retrieval paradigm. Infant retrieval was shown by 5 out of 17 monkeys (29%) in their first test. The rate of retrieval increased to 10 monkeys (59%) by the fourth test. No significant differences in age, sex, or housing condition existed between monkeys that retrieved infants and those not retrieving. Prolactin concentrations were significantly elevated in serum obtained after testing only in monkeys that retrieved infants. Prolactin levels after infant exposure were positively related to carrying duration. A separate experiment verified that neither prolactin nor cortisol was significantly elevated in response to prolonged handling. Cortisol levels were inversely proportional to handling time. Prolactin levels were not significantly related to handling time. Our results indicate that alloparental behavior is expressed at high rates after minimal infant experience, and prolactin levels rise concomitantly with the expression of alloparental behavior in this species.

Unrelated umbilical cord stem cell transplantation for X-linked immunodeficiencies

Banked unrelated umbilical cord blood matched at 5 of 6 human leukocyte antigen loci was used to reconstitute the immune system in 2 brothers with X-linked lymphoproliferative syndrome and 1 boy with X-linked hyperimmunoglobulin-M syndrome. Pretransplant cytoreduction and posttransplant graft-versus-host prophylaxis were given. Hematopoietic engraftment and correction of the genetic defects were documented by molecular techniques. Two years after transplantation, all 3 patients have normal immune systems. These reports support the wider use of banked partially matched cord blood for transplantation in primary immunodeficiencies.

Hypoxic/ischemic insult alters ferritin expression and myelination in neonatal rat brains

Ferritin is expressed very early in the development of oligodendrocytes. This protein makes iron available within cells while providing some protection from iron-induced oxidative damage. In the developing rat brain, ferritin is found initially in microglia followed by oligodendrocytes in a temporal and spatial pattern that coincides with the expression of myelin. In this study, we test the hypothesis that hypoxic/ischemic (H/I) insult will alter the expression of ferritin in microglia and oligodendrocytes, resulting in a delay in the appearance of myelin markers. Seven-day-old rat pups were exposed to H/I insult. Within 24 hours, after the insult, there is an increase in ferritin-positive amoeboid microglia and a decrease in immunohistochemical reaction for the myelin marker Rip in the brain. The oligodendrocyte marker 2'-3'-cyclic nucleotide 3'-phosphodiesterase is elevated in the H/I hemisphere relative to the hypoxia-only hemisphere between 8 and 15 days after insult. By 23 days after the insult, the subcortical white matter segregates into areas that contain ferritin-positive microglia and are devoid of Rip-positive oligodendrocytes or areas with Rip-positive cells and no ferritin-positive microglia. The H/I insult also affects the ratio of H-rich to L-rich ferritin expression at most of the time periods. These results demonstrate that the type of ferritin, its cellular distribution and the normal pattern of subcortical white matter myelination is affected by H/I. We propose that the absence of ferritin in oligodendrocytes prohibits them from storing sufficient iron to meet the synthetic and metabolic demands associated with myelination.

Bromocriptine administration lowers serum prolactin and disrupts parental responsiveness in common marmosets (Callithrix j. jacchus)

The influence of prolactin on parental responsiveness was investigated in eight unpaired, parentally inexperienced common marmosets (Callithrix jacchus; 6 female, 2 male). The marmosets were prescreened with infants (1-10 days of age) and required to exhibit short latency retrieval and infant carrying in at least three consecutive pretests as criterion for inclusion in this study. The marmosets were then administered the dopamine agonist bromocriptine (0.5 mg/0.5ml vehicle subcutaneously) and the vehicle alone (0.5 ml 10% ethanol solution) twice daily for 3 consecutive days in random order. Bromocriptine treatment reduced circulating prolactin to nondetectable levels. Bromocriptine treatment eliminated infant retrieval in four of the eight marmosets and was associated with significantly increased retrieval latencies and significantly reduced carrying durations in the four monkeys that continued to retrieve following bromocriptine treatment. When given the vehicle alone, the marmosets retrieved infants significantly faster than during pretests, suggesting a handling effect of the injection series. Bromocriptine treatments were associated with significantly increased movement during the tests. The results of this study indicate that prolactin and/or its regulatory neurotransmitters are involved in the control of the spontaneous display of parental responsiveness in common marmosets.

Dynamics of rab5 activation in endocytosis and phagocytosis

Fluid-phase endocytosis is stimulated by H-ras-linked growth factor receptors and this stimulation requires activation of rab5. We utilized a GFP-rab5a:wt fusion protein to monitor GFP-rab5a:wt activation in living fibroblasts and in J774 macrophages. Control CHO cells that expressed GFP-rab5a:wt were cultured in serum-free conditions and showed GFP-rab5a:wt localized to endosomal vesicles with a mean diameter of 0.3 +/- 0.1 microm. Endosome fusion, membrane ruffling, and pinosome formation were rarely detected in these cells. Coexpression of H-ras:G12V, a constitutively active H-ras mutant that activates rab5a, in cells resulted in marked enlargement of labeled endosomes (mean diameter 0.7 +/- 0.2 microm) and large numbers of giant GFP-rab5a:wt-positive endosomes were present. Time-lapse recordings showed abundant fusion among giant labeled endosomes, and membrane ruffling and pinosome formation were commonly observed. Alterations in GFP-rab5a:wt endosome structure and activity in cells expressing H-ras:G12V were linked to rab5a activation because these changes were identical to those found in cells expressing GFP-rab5a:Q79L, a constitutively activated rab5a mutant. Furthermore, cells co-expressing H-ras:G12V and GFP-rab5a:S34N, an inactive rab5a mutant, exhibited no evidence of H-ras:G12V-induced endosome enlargement. To observe changes in endosome structure and activity that directly followed activation of GFP-rab5a:wt, we performed time-lapse recordings of cells cultured overnight in serum-free media after addition of EGF. EGF caused a rapid increase in endosome fusion and in membrane ruffling activity. Membrane ruffling was often associated with GFP-rab5a:wt-positive vesicle (pinosome) formation at the base of membrane ruffles. Endosome and pinosome fusion were common in EGF-stimulated cells. Phagocytosis is also regulated by GFP-rab5a:wt. J774 macrophages that expressed GFP-rab5a:wt showed transiently activation and recruitment of GFP-rab5a:wt to newly formed phagosomes that contained rhodamine-labeled Escherichia coli. These studies show that GFP-rab5a:wt activation results in dynamic alterations in the structure and activity of the early endosomal and early phagosomal elements.

Epidermal growth factor and membrane trafficking. EGF receptor activation of endocytosis requires Rab5a

Activated epidermal growth factor receptors recruit various intracellular proteins leading to signal generation and endocytic trafficking. Although activated receptors are rapidly internalized into the endocytic compartment and subsequently degraded in lysosomes, the linkage between signaling and endocytosis is not well understood. Here we show that EGF stimulation of NR6 cells induces a specific, rapid and transient activation of Rab5a. EGF also enhanced translocation of the Rab5 effector, early endosomal autoantigen 1 (EEA1), from cytosol to membrane. The activation of endocytosis, fluid phase and receptor mediated, by EGF was enhanced by Rab5a expression, but not by Rab5b, Rab5c, or Rab5a truncated at the NH(2) and/or COOH terminus. Dominant negative Rab5a (Rab5:N34) blocked EGF-stimulated receptor-mediated and fluid-phase endocytosis. EGF activation of Rab5a function was dependent on tyrosine residues in the COOH-terminal domain of the EGF receptor (EGFR). Removal of the entire COOH terminus by truncation (c'973 and c'991) abrogated ligand-induced Rab5a activation of endocytosis. A "kinase-dead" EGFR failed to stimulate Rab5a function. However, another EGF receptor mutant (c'1000), with the kinase domain intact and a single autophosphorylation site effectively signaled Rab5 activation. These results indicate that EGFR and Rab5a are linked via a cascade that results in the activation of Rab5a and that appears essential for internalization. The results point to an interdependent relationship between receptor activation, signal generation and endocytosis.

Reduction of hypoxic-ischemic brain swelling in the neonatal rat with PAF antagonist WEB 2170: lack of long-term protection

Platelet activating factor (PAF) is an inflammatory lipid mediator released by ischemic brain. Our objectives were to use an inhibitor of PAF that does not readily cross the blood-brain barrier, WEB 2170, to study the role of intravascular PAF on brain swelling and subsequent brain atrophy in a neonatal rat model of hypoxic-ischemic brain injury. We injured the right cerebral hemisphere of 7-d-old rats by ligating the right common carotid artery and exposing the rats to 8% oxygen for 2.25 h. Forty-two rats received saline or the PAF antagonist WEB 2170, 1 h before hypoxia. We found that WEB 2170 pretreatment reduced swelling by 64% (p = 0.003). In contrast, treatment immediately after hypoxic-ischemic injury did not reduce swelling. In two additional experiments involving 103 rats, we found that pretreatment or repeated doses of PAF antagonist before and after hypoxic-ischemic injury did not reduce atrophy. We also found that the brain-penetrating PAF antagonist, BN 52021, did not prevent atrophy in our Wistar rat model. In conclusion, we were unable to reduce long-term brain injury with either PAF antagonist. WEB 2170 pretreatment reduced brain swelling by 64% without reducing atrophy. This suggests that although brain swelling may accompany cerebral infarction, it does not contribute to the pathogenesis of infarction and subsequent atrophy in the neonatal rat. The ability to reduce early postischemic brain swelling without reducing atrophy may be particularly unique to the immature animal with a compliant skull.

Endosome fusion in living cells overexpressing GFP-rab5

CHO and BHK cells which overexpress either wild-type rab5 or rab5:Q79L, a constitutively active rab5 mutant, develop enlarged cytoplasmic vesicles that exhibit many characteristics of early endosomes including immunoreactivity for rab5 and transferrin receptor. Time-lapse video microscopy shows the enlarged endosomes arise primarily by fusion of smaller vesicles. These fusion events occur mostly by a ‘bridge’ fusion mechanism in which the initial opening between vesicles does not expand; instead, membrane flows slowly and continuously from the smaller to the larger endosome in the fusing pair, through a narrow, barely perceptible membranous ‘bridge’ between them. The unique aspect of rab5 mediated ‘bridge’ fusion is the persistence of a tight constriction at the site where vesicles merge and we hypothesize that this constriction results from the relatively slow disassembly of a putative docking/fusion complex. To determine the relation of rab5 to the fusion ‘bridge’, we used confocal fluorescence microscopy to monitor endosome fusion in cells overexpressing GFP-rab5 fusion proteins. Vesicle docking in these cells is accompanied by recruitment of the GFP-rab5 into a brightly fluorescent spot in the ‘bridge’ region between fusing vesicles that persists throughout the entire length of the fusion event and which often persist for minutes following endosome fusion. Other endosomal membrane markers, including FM4-64, are not concentrated in fusion ‘bridges’. These results support the idea that the GFP-rab5 spots represent the localized accumulation of GFP-rab5 between fusing endosomes and not simply overlap of adjacent membranes. The idea that the GFP-rab5 spots do not represent membrane overlap is further supported by experiments using photobleaching techniques and confocal imaging which show that GFP-rab5 localized in spots between fusion couplets is resistant to diffusion while GFP-rab5 on endosomal membranes away from these spots rapidly diffuses with a rate constant of about 1.0 (+/-0.3) x10(-)(9)cm(2)/second.

Immune thrombocytopenia after umbilical cord progenitor cell transplant: response to vincristine

An 8-month-old male with X-linked lymphoproliferative disease underwent an unrelated, partially matched (with major mismatch at DR locus), cord blood stem cell transplant. Four months following the transplant, he developed immune thrombocytopenia with hemolytic anemia (Evans syndrome). He received multiple courses of intravenous immunoglobulin, anti-Rh D immunoglobulin, a pulse of high-dose corticosteroids and cyclosporine with some improvement of hemolytic anemia, but no improvement of the thrombocytopenia. Addition of vincristine, resulted in long-term resolution of thrombocytopenia and anemia. No major toxicity was observed during treatment. Vincristine should be considered as a treatment for refractory immune thrombocytopenia after hematopoietic stem cell transplantation.

Endocytic active zones: hot spots for endocytosis in vertebrate neuromuscular terminals

We have used a sensitive activity-dependent probe, sulforhodamine 101 (SR101), to view endocytic events within snake motor nerve terminals. After very brief neural stimulation at reduced temperature, SR101 is visualized exclusively at punctate sites located just inside the presynaptic membrane of each terminal bouton. The number of sites (approximately 26 sites/bouton) and their location (in register with postsynaptic folds) are similar to the number and location of active zones in snake motor terminals, suggesting a spatial association between exocytosis and endocytosis under these stimulus conditions. With more prolonged stimulation, larger SR101-containing structures appear at the bouton margins. Thus endocytosis occurs initially at distinct sites, which we call "endocytic active zones," whereas further stimulation recruits a second endocytic paradigm.

Changes in iron histochemistry after hypoxic-ischemic brain injury in the neonatal rat

Iron can contribute to hypoxic-ischemic brain damage by catalyzing the formation of free radicals. The immature brain has high iron levels and limited antioxidant defenses. The objective of this study was to describe the early alterations in nonheme iron histochemistry following a hypoxic-ischemic (HI) insult to the brain of neonatal rats. We induced a HI insult to the right cerebral hemisphere in groups of 7-day-old rats. Rats were anesthetized, then their brains were perfused and fixed at 0, 1, 4, 8, 24 hr, and 1, 2, and 3 weeks of recovery. Forty-micron-thick frozen sections were stained for iron using the intensified Perls stain. Increased iron staining was first detected within the cytoplasm of cells with pyknotic nuclei at 4 hr of recovery. Staining increased rapidly over the first 24 hr in regions of ischemic injury. By 7 days recovery, reactive glia and cortical blood vessels also stained. Increased staining in gray matter persisted at 3 weeks of recovery, whereas white matter tracts had fewer iron-positive cells compared to normal. The early increase in iron staining could be caused by an accumulation of iron posthypoxicischemic injury or a change in iron from nonstainable heme iron to stainable nonheme iron. Regardless of the source, our results indicate that there is an increase in iron available to promote oxidant stress in the neonatal rat brain following hypoxia-ischemia.

Prolonged mating in prairie voles (Microtus ochrogaster) increases likelihood of ovulation and embryo number

Prairie voles are induced ovulators that mate frequently in brief bouts over a period of approximately 24 h. We examined 1) impact of mating duration on ovulation and embryo number, 2) incidence of fertilization, 3) temporal pattern of embryo development, 4) embryo progression through the reproductive tract over time, and 5) embryo development in culture. Mating was videotaped to determine first copulation, and the ovaries were examined and the reproductive tracts flushed at 6, 8, 10, 12, 16, 20, and 24 h and 2, 3, and 4 days after first copulation. The number of mature follicles and fresh corpora lutea and the number and developmental stage of embryos were quantified. One, two-, and four-cell embryos were cultured in Whitten's medium. Mature follicles were present at the earliest time examined (6 h). Thirty-eight percent of females that had been paired for < 12 h after the first copulation ovulated, whereas all females paired >/= 12 h after the first copulation ovulated. Virtually all (> 99%) oocytes recovered from females paired for >/= 12 h after first copulation were fertilized. Pairing time after first copulation and mean copulation-bout duration were significant (p < 0.05) determinants of embryo number. Embryos entered the uterine horns and implanted on Days 3 and 4, respectively, after first copulation (Day 0). Embryos cultured in vitro underwent approximately one cell division per day, a rate similar to that in vivo. We conclude that prairie voles ovulate reliably after pairing for >/= 12 h, although some females showed exceptional sensitivity not predicted by the variables quantified. Prolonged mating for longer than 12 h increased the total embryos produced. This mechanism likely has adaptive significance for increasing offspring number.

Effect of interleukin (IL)-12 and IL-15 on activated natural killer (ANK) and antibody-dependent cellular cytotoxicity (ADCC) in HIV infection

The ability of IL-12 and IL-15 to enhance natural killer (NK) activity and antibody-dependent cellular cytotoxicity (ADCC) of mononuclear cells (MNCs) from HIV+ children and their mothers was investigated. MNCs from HIV+ patients were deficient in NK and ADCC activity compared to control MNCs against several target cells. Overnight incubation with IL-15 or IL-12 augmented NK activity of MNCs from both patients and controls, and the combination of IL-12 and IL-15 resulted in the greatest enhancement. ADCC in HIV+ patients against gp120-coated CEM.NKR cells or chicken erythrocytes could also be enhanced by IL-2 or IL-15 in overnight cultures. Culturing MNCs with either IL-2 or IL-15 for 1 week increased the NK activity in patients to levels of controls treated with these cytokines. However, the response to the combination of IL-12 and IL-15 was less than that to IL-15 alone in 1-week cultures. Culturing MNCs with IL-2 and IL-15 for 1 week also increased the percentage of CD16+/CD56+ cells in both patients and controls. Thus, IL-15 can restore the deficient NK activity in patients and may be a candidate for immunomodulative therapy in HIV+ patients.

Interleukin (IL)-15 enhances antibody-dependent cellular cytotoxicity and natural killer activity in neonatal cells

Interleukin (IL)-15 is a novel cytokine that is very similar to IL-2 in receptor specificity and biological activities. We compared the ability of IL-15 and IL-12 to enhance the cytotoxicity of neonatal (cord blood) and adult mononuclear cells (MNC) in both natural killer (NK) and antibody-dependent cellular cytotoxicity (ADCC) assays. Incubation with IL-15 (10 ng/ml) or IL-12 (1 ng/ml) for 18 h enhanced the NK activity (using K562 target cells) of both cord and adult MNC, increasing cord cell cytotoxicity threefold. Similar enhancement was seen in ADCC assays using erythrocyte targets and NK-resistant CEM cells coated with HIV gp-120 antigen. Incubation of cord cells with IL-15 or IL-12 for 1 week increased both NK and ADCC, although the combination produced less of an effect than either cytokine alone. IL-15 also increased the percentage of CD16+/CD56+ cells after 1 week incubation. This enhancement of NK and ADCC activities and the number of NK cells by IL-15 suggests it may be clinically useful in treating immunodeficient patients.

Cooperative breeding and monogamy in prairie voles: influence of the sire and geographical variation

Mammalian monogamy is characterized by pair bonding and a relative absence of sexual dimorphism in body size. Alloparental behaviour is a characteristic of mammalian cooperative breeding systems. Studies of prairie voles, Microtus ochrogaster, from stock captured in a resource-abundant habitat in Illinois have supported the assumption that this species is a monogamous, cooperative breeder, while other studies of prairie voles from a more arid habitat in Kansas have called this assumption into question. We hypothesized that reported differences between these populations represented true intraspecific variation. Patterns of sexual dimorphism in body size, partner preferences and parental contact behaviour were compared in prairie voles from stocks originating in Illinois or Kansas. Both Illinois and Kansas voles showed a strong preference for a familiar partner, which is suggestive of monogamy. Sexual dimorphism in body size was observed in Kansas, but not Illinois voles. Illinois voles displayed significantly higher levels of parental contact behaviour than did voles from Kansas. When animals from Illinois and Kansas were crossed, the expression of parental contact behaviour of the 'hybrid' offspring followed the pattern seen in the population of origin of the sire. Removal of the sire prior to the birth of the litter increased alloparenting in Kansas voles, but removal of the sire was associated with lower levels of alloparenting in Illinois voles. Thus, some traits associated with the social system may show intraspecific variation and can be influenced by the presence or absence of the sire during rearing. Copyright 1998 The Association for the Study of Animal Behaviour. Copyright 1998 The Association for the Study of Animal Behaviour.

Intraspecific variation in the induction of female sexual receptivity in prairie voles

Prairie voles (Microtus ochrogaster) are monogamous New World rodents which show geographic variation in social behavior. In this study, parameters of female reproduction which might be related to mating system were compared in prairie voles from eastern Kansas (KAN) versus central Illinois (ILL). KAN females showed a more rapid onset of natural estrus following exposure to a male and were more likely to respond to injections of a low dose (0.5 microg) of exogenous estradiol benzoate than ILL females. Neither mating duration nor pregnancy success after mate removal differed in KAN versus ILL females. These results suggest that ILL voles are less sensitive than KAN voles to the estrus-inducing effects of either endogenous or exogenous estrogen, supporting the hypothesis that variations in reproductive strategy occur among geographically discrete populations of prairie voles.

Enhancement of antibody-dependent cellular cytotoxicity of neonatal cells by interleukin-2 (IL-2) and IL-12

Newborn infants are more susceptible to infections due in part to deficiencies in the cytotoxic functions of their lymphocytes. We investigated the ability of interleukin-2 (IL-2) and IL-12 to enhance the cytotoxicity of neonatal (cord blood) and adult mononuclear cells (MNCs) in both natural killer (NK) cell and antibody-dependent cellular cytotoxicity (ADCC) assays. The cytotoxic activity of cord blood MNCs was less than 50% that of adult MNCs in most assays prior to exposure to cytokines. Incubation with IL-2 (100 U/ml) or IL-12 (1 ng/ml) for 18 h increased the NK cell activity (using K562 target cells) of both cord blood and adult MNCs, and the combination of IL-2 and IL-12 increased cord blood cytotoxicity threefold, making the cytotoxicity of cord blood cells equivalent to that of adult cells treated with the same cytokines. In ADCC assays with chicken erythrocyte targets, the combination of IL-2 and IL-12 increased the cytotoxicities of both cord blood and adult MNCs, with greater enhancement again seen with cord blood cells. In assays with NK cell-resistant CEM cells coated with human immunodeficiency virus (HV) gp120 antigen in the presence of hyperimmune anti-HIV immunoglobulin, ADCC of cord blood MNCs was about 50% that of adult MNCs; ADCC of cord blood MNCs increased two- to threefold with the addition of IL-2 and IL-12, whereas ADCC of adult MNCs did not increase. Incubation of cord blood cells, but not adult cells, with IL-2 or IL-12 for 1 week increased the percentage of CD16+/CD56+ cells two- to fivefold and enhanced ADCC activity. Thus, IL-2 and IL-12 greatly enhance both the NK cell and ADCC activities of neonatal MNCs and increase the number of NK cells in longer-term culture.

Sexual differentiation in prairie voles: the effects of corticosterone and testosterone

Prairie voles (Microtus ochrogaster) exhibit low levels of physical sexual dimorphism and have endogenous basal corticosterone levels that are 5-10 times higher than those measured in rats; prairie voles also do not show a postnatal period of adrenal hyporesponsivity. On the basis of studies in rats suggesting that adrenal hyperactivity during the perinatal period could reduce masculinization or feminize sexual behavior, we hypothesized that adrenal hormones might influence sexual differentiation in prairie voles. We also examined the hypothesis that the effects of testosterone in prairie voles might differ from those reported in other rodents. Treatments with either corticosterone or testosterone propionate (TP) were given prenatally (gestational Days 12-20), via maternal injection, or postnatally (Days 1-6), by directly injecting the pups. Additional groups of males were castrated or sham-operated on postnatal Day 1, and a subgroup of castrated males received postnatal TP. Male and female sexual behavior was observed in adulthood following gonadectomy and hormone treatments. Corticosterone treatment was associated with high levels of mounting in both sexes and did not inhibit lordosis behavior in females. Postnatal TP treatment inhibited lordosis in females but did not facilitate mounting in either sex. Males that were castrated at birth showed unexpectedly high levels of mounting in response to adult androgens. The results of this study suggest that in prairie voles corticosterone is capable of masculinizing without defeminizing sexual behavior, whereas postnatal testicular secretions are not essential for, and may actually inhibit, masculinization in this species.

Treatment of chronic recurrent multifocal osteomyelitis with interferon gamma

Chronic recurrent multifocal osteomyelitis is characterized by recurrent episodes of painful swollen lesions of the bone and overlying skin with radiographic changes and an elevated sedimentation rate. It resembles infectious osteomyelitis but with negative findings on bacterial culture and no response to antibiotics. We treated a 13-year-old girl with interferon gamma for 3 months. She had 11 episodes of chronic recurrent multifocal osteomyelitis in 2 1/2 years before therapy and has had none in the 15 months since therapy, an outcome suggesting a favorable therapeutic response.

14-3-3 proteins are essential for RAS/MAPK cascade signaling during pseudohyphal development in S. cerevisiae

14-3-3 proteins are highly conserved ubiquitous proteins whose explicit functions have remained elusive. Here, we show that the S. cerevisiae 14-3-3 homologs BMH1 and BMH2 are not essential for viability or mating MAPK cascade signaling, but they are essential for pseudohyphal-development MAPK cascade signaling and other processes. Activated alleles of RAS2 and CDC42 induce pseudohyphal development and FG(TyA)-lacZ signaling in Bmh+ strains but not in ste20 (p65PAK) or bmh1 bmh2 mutant strains. Moreover, Bmh1p and Bmh2p associate with Ste20p in vivo. Three alleles of BMH1 encode proteins defective for FG(TyA)-lacZ signaling and association with Ste20p, yet these alleles complement other 14-3-3 functions. Therefore, the 14-3-3 proteins are specifically required for RAS/MAPK cascade signaling during pseudohyphal development in S. cerevisiae.

The role of neutrophils in the production of hypoxic-ischemic brain injury in the neonatal rat

Neutrophils contribute to ischemic brain injury in adult animals. The role of neutrophils in perinatal hypoxic-ischemic (HI) brain injury is unknown. Allopurinol reduces neutrophil accumulation after tissue ischemia and is protective against HI brain injury. This study was designed to investigate how neutrophils contribute to perinatal hypoxic ischemic brain injury and how neutropenia compared with allopurinol in its neuroprotective effects. A HI insult was produced in the right cerebral hemisphere of 7-d-old rats by right common carotid artery ligation and systemic hypoxia. Half the rats were rendered neutropenic with an anti-neutrophil serum (ANS). At 15 min of recovery from hypoxia, half the neutropenic and nonneutropenic rats received allopurinol (135 mg/kg, s.c.). The protective effect of the four treatment combinations was determined on brain swelling at 42 h of recovery. Neutropenia reduced brain swelling by about 70%, p < 0.01. Allopurinol alone produced similar protection so that the relatively small number of animals studied did not permit assessment of an additive effect. Neutrophil accumulation in cerebral hemispheres was measured by myeloperoxidase (MPO) activity assay and by neutrophil counts in 6-microm sections stained by MPO and ANS immunostaining. MPO activity peaked between 4 and 8 h of recovery in both hemispheres. Hemispheric neutrophil counts peaked at the end of the HI insult and again at 18 h of recovery. Neutrophils were stained within blood vessels and did not infiltrate the injured brain before infarction had occurred. We conclude that neutrophils contribute to HI brain injury in the neonate and that neutrophil depletion before the insult is neuroprotective.

Antibody-directed natural cytotoxicity results in enhanced killing of HIV gp120-coated CEMNKR cells

Cellular cytotoxicity may be an important defense in the control of HIV progression. In the present study antibodies were attached to peripheral blood mononuclear cells (PBMC) by exposing them to polyethylene glycol and phthalate oil in the presence of HIV human hyperimmune IVIG (HIVIG). The attachment procedure is known as "franking" and the resultant cytotoxicity is termed "antibody-directed." The majority of the cells that are franked with attached HIVIG are CD16+ (Fc gamma RIII), placing them in the natural killer cell population. Franking increased the cytotoxicity of PBMC from both healthy controls and HIV-seropositive patients approximately fourfold compared to conventional antibody-dependent cellular cytotoxicity using CEM cells coated with HIV gp120 antigen as targets. Use of anti-HIV monoclonal antibodies for franking was less efficient than polyclonal HIVIG. The HIVIG-franked PBMC suppressed p24 production of in vitro HIV IIIb-infected human PBMC. The ability of HIVIG to enhance and direct cytotoxicity to HIV targets may suggest a new therapeutic approach to HIV control.

Human immunodeficiency virus (HIV) type-1 GP120-specific cell-mediated cytotoxicity (CMC) and natural killer (NK) activity in HIV-infected (HIV+) subjects: enhancement with interleukin-2(IL-2), IL-12, and IL-15

Cell-mediated cytotoxicity (CMC), as mediated by cytophilic antibody to human immunodeficiency virus (HIV) antigens, may be an important defense in HIV-infected (HIV+) patients in response to the virus. In this study the ability of interleukin (IL)-2, IL-12, and IL-15 to enhance natural killer (NK) and gp120-specific CMC of mononuclear cells (MNCs) from HIV+ children and adults was examined. NK activity against K562 cells was deficient in HIV+ patients compared to controls and could be enhanced by IL-2, IL-12, or IL-15, with the combinations of IL-2 + IL-12 and IL-12 + IL-15 producing more cytotoxicity than individual cytokines. Gp120-specific CMC was significantly higher in patients than in controls. It could be increased by IL-2, IL-12, and IL-15 and further by combining IL-2 and IL-12. When an exogenous source of antibody in the form of hyperimmune HIV-specific immunoglobulin (HIVIG) was present, the response of control MNCs was much higher than that of patients, although gp120-specific cytotoxicity of patients' MNCs was significantly enhanced (two- to threefold) by the addition of HIVIG. This increment in cytotoxicity due to HIVIG, however, could not be further augmented by cytokines in controls or patients. Our findings suggest multiple cytokine administration to boost NK cell function, together with passive immunotherapy, might offer a new therapeutic approach to benefit HIV+ patients.

Perinatal hormone exposure alters the expression of selective affiliative preferences in prairie voles

In the present study, perinatal administration of corticosterone and testosterone significantly influenced affiliative preferences only in females. Despite the very high levels of steroids given, no significant differences were noted among treated and untreated groups of males. Prairie voles apparently are uniquely adapted to tolerate high levels of endogenous steroids. However, females of this species may be capable of exploiting variations in corticosterone levels to regulate sexually dimorphic traits, including social behaviors, in adulthood. Perinatal responsivity to adrenal hormones could allow animals to adapt their social behaviors, including traits that have been used to characterize monogamy and/or communal breeding, to environmental demands.